Grisez, Germain

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The Linacre QuarterlyVolume 64 | Number 2 Article 4May 1997Difficult Moral Questions: May a PhysicianRemain in a Group That Provides ImmoralServices?Germain GrisezFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationGrisez, Germain (1997) "Difficult Moral Questions: May a Physician Remain in a Group That Provides Immoral Services?," TheLinacre Quarterly: Vol. 64: No. 2, Article 4.Available at: http://epublications.marquette.edu/lnq/vol64/iss2/4• I ~ Difficult Moral Questions: May a Physician Remain in a Group That Provides Immoral Services? by Germain Grisez Professor Grisez, who serves on the Linacre Quarterly editorial advisory board, is on the faculty of Mount Saint Mary's College, Emmitsburg, MD 21727. The following is one of the questions that I am preparing for Difficult Moral Questions, which will be the third volume of The Way of the Lord Jesus. The response given here will be revised further before the book is published. So, I will welcome readers' letters with criticisms and suggestions for improvement. I also will be glad to receive other difficult moral questions to which readers have been unable to obtain an answer. Statement of the question: I am a physician in family practice with a small health maintenance group. It includes three primary care physicians (one an internist), a pediatrician, an obstetrician-gynecologist, a general surgeon, and a psychiatrist - all of us at least should-be Catholics. We use a community hospital (which is not Catholic) and refer when necessary to specialists in a nearby larger city, where there also is a well-equipped hospital. But we can take care of most of the health care needs of our patients, and in most respects the arrangement has worked well. When we set the group up some years ago, we agreed to adhere to the U.S. Bishops' Ethical and Religious Directives and to tell patients who asked about contraception, sterilization, or abortion: "We do not offer that sort of thing." In his previous practice, the obstetrician-gynecologist (whom I'll call "Dr. Lemon"), had refused on medical grounds to prescribe oral contraceptives or IUDs. But he insisted upon - and all of us recognized - the need to help our patients with birth regulation. Since the others were not interested, the pediatrician, "Dr. White," and I accepted responsibility for teaching natural family planning. May, 1997 21 It was not long, however, before White and I realized that Lemon was fitting diaphragms and recommending nonprescription contraceptives to many women. When confronted, he admitted that he had been "cheating a little on our agreement." But Lemon defended what he was doing as "the least of three evils" for couples who will not practice NFP consistently, arguing that, if he did not help them to limit their families satisfactorily, many couples would leave our group and go elsewhere for oral contraception, sterilization, and abortion. Since the group needed an obstetrician-gynecologist and it would have been almost impossible to replace Lemon, the others did not wish to press the issue, and White and I reluctantly let it drop. Recently, however, Lemon began prescribing oral contraceptives. White and I again confronted him, and he said that, on his reading of the more recent , literature, the lower-dosage oral contraceptives are medically acceptable. Lemon also argued that the group must offer "more satisfactory family planning services" if we are to retain an adequate clientele. White and I objected that all oral contraceptives sometimes act as abortifacients, but the others sided with Lemon and agreed that he not only could prescribe them but do sterilizations and refer patients to a physician outside the group for abortion. They also decided, despite our protests, that from now on no one in the group would say that we do not offer that sort of thing; instead, everyone would direct patients "needing" contraception, sterilization, or abortion to Lemon. Even White agreed to go along. I said I would think about it, and they left it go at that until next month. However, I either must go along or leave the group. That would be difficult for me personally, since I would not be able to take any of the patients with me, but would have to uproot my wife and children, and begin practice all over again in some other place. So, up to now, I have been trying to work out a modus vivendi I continue to advocate natural family planning and, beleving that nobody needs contraception, sterilization, or abortion, never bring them up. No patient has brought up abortion with me; not only do our patients know where I stand, but those who are pregnant, or think they might be, can go directly to Lemon and normally do. But a few have asked about contraception, and I say: "I don't want have anything to do with that sort of thing; you must see Dr. Lemon about it." I think this approach will satisfy the others, but my conscience is bothering me. Also, I really am worried as to whether I could say the same thing if someone does bring up sterilization or abortion. Analysis: The-obstetrician-gynecologist is, or will be, doing sterilizations, and formally cooperating in contraception and abortion. The majority of the group is pressing the questioner to cooperate in all this. Though this cooperation under duress would be, not formal, but material, the usual norms regarding material cooperation must be applied. Their application indicates that, even if the questioner's cooperation is as minimal as possible, it will be morally unacceptable.-The questioner should investigate alternatives to the two he mentions, that is, either cooperating or simply leaving the group. But in my 22 Linacre Quarterly • judgment, if none proves workable and acceptable, he should leave. A suitable reply might be along the following lines: In directing patients who ask about contraception, sterilization, and abortion to Dr. Lemon, you are cooperating with his actions in respect to these matters. He is or will be doing sterilizations. In prescribing oral contraceptives, which Lemon regards as an appropriate method of birth regulation, he certainly intends that they be used effectively, and so formally cooperates in their use, perhaps also intending, but certainly at least wrongly accepting, their sometimes-abortifacient mode of action. Also, in referring patients to an abortionist, which Lemon regards as an element of adequate family planning services, he plainly will intend that the abortion be obtained, and so will formally cooperate in it. Of course, your involvement in contraception, sterilization, and abortion will be able to remain comparatively indirect. Holding that these contralife procedures are not appropriate methods of family planning and that nobody needs them, you do not bring them up. Thus far, you have told only those patients who ask about contraception that you do not want to have anything to do with that sort of thing and that they must see Lemon about it, and you are considering saying the same thing to those who bring up sterilization or abortion. In saying this, you need not intend that patients see Lemon, much less that he do, or help them to do, anything immoral. Your intention can be, and undoubtedly is and would be, simply to do what is necessary to remain in the group. So, in responding to patients' inquiries, your cooperation with Lemon's wrongdoing is only material. Still, even material cooperation is morally unacceptable if it is likely to lead one to cooperate formally, if it gives scandal or impedes bearing witness as one should, or if it is unfair to anyone. You might suppose that you may refer patients to Lemon, much as a physician who is not in a group but under other pressures may refer patients to someone who will accomodate them, at least by suggesting a referral service. Your situation, however, differs from that of such a physician. Since you do belong to a group, your professional work and that of the group's other members ordinarily is formal cooperation for the common good, which is your patients' well being and community among yourselves. This common good is understood by everyone concerned, and patients you refer to Lemon also will remain your patients. When you refer someone to him, you know what he will do, and the patient is aware that you know. This state of affairs will affect profoundly the significance of your material cooperation. You certainly will be tempted to cooperate formally with Lemon. Caring for the same patients, you cannot help intending with him their survival and good health. So, knowing that wrong things are being done, you will try to forestall their injurious effects on patients. If Lemon prescribes a contraceptive, you will be concerned that the patient take it correctly and deal appropriately with side effects; if Lemon is planning to do a sterilization, you will be concerned that the couple understand what sterilization is and that the patient be uncoerced in consenting to it; and if Lemon might refer someone for an abortion, you will be May, 1997 23 concerned that it not be late in pregnancy when it would be more dangerous to the mother. Caring for your patients even as they engage in contralife acts, you will be tempted to join them in intending the bad means they are using to attain their ulterior good ends. Even if you avoid formal cooperation, your material cooperation with Lemon, which inevitably will be extensive, is likely to lead at least some of your patients who otherwise would resist temptation to give in to it. Since you have adhered to Catholic teaching up to now, your going along with the group's change of policy will strongly suggest that contraception, sterilization, and abortion are not so wrong after all, and this suggestion will encourage people to rationalize the choice of what what they previously regarded wrong. At the same time, you will be inhibited from bearing credible witness to the truth, that is, saying clearly what 111 you believe about these contralife actions and acting in unambiguous harmony with what you say. The point is especially clear and serious with respect to abortion, which someone is certain to bring up sooner or later. If you say, "I don't want to have anything to do with that sort ofthing; you must see Dr. Lemon about it, " you will give the impression that you regard abortion, not as wrong in itself, but only as personally repugnant. Moreover, even such material cooperation in abortion raises a very serious question offairness to the unborn child. If you were in his or her place, would you not wish a pro-life physician your mother consulted to do everything possible to dissuade her from killing you? Nor are issues of fairness absent from material cooperation with the prescribing of oral contraceptives. As you and White argued, they sometimes work as abortifacients. Moreover, they do not always work, and then a child comes to be as unwanted - and is likely to be either aborted or resented and, perhaps, abused. Consequently, it seems to me clear that you may not comply with the decision of the others, even within the limits you have set. But it is not clear to me that your only alternative is simply to leave and begin an entirely new practice elsewhere. Before leaving, unless you already have consulted an attorney competent in such matters, I think you should do so. Perhaps the agreement you made when the group was set up - to practice in accord with the Church's teaching ~ -remains legally binding on the others so that they cannot amend it without unanimous consent. In that case, you can insist that the others abide by the original agreement. Perhaps the status of the agreement is not so clear, but their position would not be easily defended. In that case, you perhaps can refuse to leave, refuse to cooperate with the new policy, and even openly oppose it. The resulting conflict will be painful for all concerned, and perhaps will lead the others to offer you some sort offair settlement. Even if the conflict drags on for a long time, your refusal to cooperate and open opposition to the others' policy would change the significance of your involvement, so that, if you are very careful, you will be able to avoid doing anything morally unacceptable. But perhaps the legal situation is clear, so that there is no question that you must cooperate, at least at the level you propose, or leave. In that case, I believe 24 Linacre Quarterly • that you must leave. Losing your share in this practice certainly will be a great sacrifice for you. However, you should compare it with the greater sacrifices, including life itself, which many other Christians gladly have made in order to keep the faith. You still will have your training and experience in a very remunerative profession. Even if you establish a new practice in some community that has been deprived of a physician due to its poverty and! or small size, you probably will be able to live as well as your neighbors, and Christians who are dedicated to service should be willing to share, insofar as necessary, the lot of those they serve. Moreover, in due time, you will be compensated very well for your present deprivation: "Blessed are those who are persecuted for righteousness' sake, for theirs is the kingdom of heaven" (Mt 5.10) . May, 1997 25 

Difficult Moral Questions: May a Physician Remain in a Group That Provides Immoral Services?

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Difficult Moral Questions: May a Physician Remain in a Group That Provides Immoral Services?

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